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Based on policy review, medical record review, central log review, diversion status report, and staff and physician interviews, the hospital failed to comply with 42 CFR §489.20 and §489.24.

Findings include:

Based on hospital policy and procedure review, medical record reviews, physician and staff interviews, the hospital's DED (Dedicated Emergency Department) physician failed to provide an appropriate medical screening examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an emergency medical condition (EMC) existed for 1 of 20 reviewed patients who presented to the DED. (Patient #1).

~cross refer to 489.24 (a) & 489.24 (c), Medical Screening Exam - Tag A2406

Based on hospital policy review, EMTALA (Emergency Medical Treatment and Labor Act) central log review and interviews, the hospital failed to maintain a central log on each individual who presented to the emergency department seeking medical care as to whether or not the patient refused treatment, or whether the patient was transferred, admitted and treated, stabilized and transferred or discharged for 1 of 20 sampled patients (#1).

Findings include:

Review of the hospital policy titled "EMTALA Policy" last reviewed 03/01/2021 revealed "The hospital maintains an electronic ED Central Log containing information on each individual who comes to the ED (Emergency Department) seeking assistance, showing whether the individual refused treatment, or was refused treatment, or whether the individual was transferred, admitted, stabilized and transferred, or discharged. The hospital will create a chart for every patient that comes to the ED."

Review of the hospital's central log for 10/09/2022 revealed Patient #1 was not listed on the central EMTALA log. No medical record available for review at Hospital A. No EMS (ambulance) run report for review at Hospital A.

Interview on 01/30/2023 at 1045 with the CEO (chief executive officer)/ED Medical Director revealed the hospital had conducted and documented the investigation concerning the EMTALA violation in October 2022. Interview revealed that the Patient (#1) arrived via private vehicle and was not registered and/or placed on the ED Central EMTALA log. Interview revealed there was no hospital ED record available to review for the Patient (#1). Interview revealed the EMTALA violation was self-reported by Hospital A "after the information was brought to our attention."

Based on hospital policy review, medical record review, diversion status report, staff schedules, physician and staff interviews, the hospital's DED (Dedicated Emergency Department) provider failed to provide an appropriate medical screening examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an emergency medical condition (EMC) existed for 1 of 20 reviewed patients who presented to the DED. (Patient #1)

Findings include:

Review of the hospital's EMTALA (Emergency Medical Treatment and Labor Act) policy last reviewed 03/01/2021 revealed that any individual who presents to the hospital's emergency department for care will receive an appropriate medical screening examination by physician or qualified medical personnel to determine if an emergency medical condition exists. Review revealed that qualified medical personnel included: a Physician or Advance Practice Professional.

No medical record for Patient #1 available for review at Hospital A. Patient #1 presented to the Emergency Department (ED) via private vehicle.

Review of the Emergency Department Diversion Report for Hospital A revealed documented diversion status for Radiology availability (X-ray and CT not available) on 10/09/2022. Review of medical records on documented radiology diversion dates revealed the patients requiring radiology (x-ray and/or CT) services received a medical screening exam at Hospital A and transfer arrangements were made with other local facilities that had availability of needed radiology services.

Review of the Radiology Staff Schedule for October 9, 2022 revealed there was no radiology staff coverage for 7a-7p and 7p-7a on October 9, 2022.

Interview on 01/30/2023 at 1045 with the CEO/ED Medical Director revealed Patient #1 did not receive a medical screening exam in the Dedicated Emergency Department. Interview revealed the ED nurse allowed Patient #1 to leave prior to receiving Medical Screening Examination.

Interview on 02/01/2023 at 1304 with Licensed Practical Nurse (LPN) #2 revealed she worked the 7p-7a shift on 10/09/2022. Interview revealed she did not hear the conversation between the Patient (#1) and the Registered Nurse (RN #1). Interview revealed RN #1 shared with her after the patient left that RN #1 had told the patient that we did not have x-ray and cat scan available, and the patient made the choice to go to another hospital. Interview revealed that Patient #1 did not come into the ED room area and was not seen by the provider.